WHO Interim Guidance for Ebola Virus Disease Exit Screening at Airports, Ports and Land Crossings 6 November 2014

Transcription

1 WHO Interim Guidance for Ebola Virus Disease Exit Screening at Airports, Ports and Land Crossings 6 November 2014 World Health Organization 1

2 WHO/EVD/Guidance/PoE/14.2 World Health Organization 2014 All rights reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Acknowledgements This guidance was prepared by WHO in collaboration with the International Civil Aviation Organization, the International Air Transport Association and the US Centers for Disease Control and Prevention, Atlanta, USA. World Health Organization 2

3 Table of Contents I. Introduction... 4 II. Planning for Exit Screening... 5 III. Communication Strategies for Exit Screening... 6 IV. Primary Screening... 7 Implementation of Primary Screening... 8 Operational Considerations for Primary Screening... 9 V. Secondary Screening Operational Considerations for Secondary Screening VI. Medical Referral VII. Travel Restrictions VIII. Data Management References APPENDICES APPENDIX 1: Summary Checklist: Exit Screening at Points of Entry APPENDIX 2: Template: Traveller Public Health Declaration Form APPENDIX 3: Secondary Screening Form APPENDIX 4: Travel Companion List Form APPENDIX 5: Primary Screening Log APPENDIX 6: Referred to Secondary Screening Log APPENDIX 7: Secondary Screening Log APPENDIX 8: Screening Log Summary Reports APPENDIX 9: WHO communication poster APPENDIX 10: Sample Ill Traveller Card World Health Organization 3

4 I. Introduction This guidance is intended for use in countries with Ebola transmission. It may also be used as a reference and as a planning tool for all countries. In August 2014, the WHO Director-General declared the Ebola virus disease (EVD) outbreak in West Africa a Public Health Emergency of International Concern, under the provisions of the International Health Regulations (IHR) The response included the following temporary recommendations for countries with Ebola transmission: States should conduct exit screening of all persons at international airports, seaports and major land crossings, for unexplained febrile illness consistent with potential EVD infection. The exit screening should consist of, at a minimum, a questionnaire, a temperature measurement and, if there is a fever, an assessment of the risk that the fever is caused by EVD. Any person with an illness consistent with EVD should not be allowed to travel unless the travel is part of an appropriate medical evacuation. There should be no international travel of EVD contacts or cases, unless the travel is part of an appropriate medical evacuation. To minimize the risk of international spread of EVD: o Confirmed cases should immediately be isolated and treated in an EVD Treatment Centre with no national or international travel until 2 EVD-specific diagnostic tests conducted at least 48 hours apart are negative; o Contacts (which do not include properly protected health workers and laboratory staff who have had no unprotected exposure) should be monitored daily, with restricted national travel and no international travel until 21 days after exposure; o Probable and suspect cases should immediately be isolated and their travel should be restricted in accordance with their classification as either a confirmed case or contact. This document provides information to assist countries in developing exit screening plans and Standard Operating Procedures (SOP). This includes the method, tools, and sequence of screening; determining resource needs; communication messages; and the legal considerations of screening. This guidance is based on the IHR (2005) framework, scientific evidence, existing international technical recommendations and standards, and lessons learned from exit screening practices in countries with EVD transmission. It was developed in collaboration with the US Centers for Disease Control and Prevention, the International Civil Aviation Organization and the International Air Transport Association. World Health Organization 4

5 Purpose and Scope of Exit Screening Exit screening is a public health intervention to identify persons with possible symptoms of, or risk of exposure to, EVD, and to prevent them from further travel. Screening measures are based upon symptom assessment and risk and can be adapted for airports, ports and ground crossings. Exit screening should be paired with travel restrictions to prevent the exportation of EVD to other countries, protect travellers and crew, and comply with public health recommendations for exposed or symptomatic persons. Effective exit screening helps prevent the introduction and spread of disease to other areas. During exit screening, travellers will be assessed for signs and symptoms of an illness consistent with EVD, or identified as contacts potentially exposed to EVD. Testing laboratory samples to determine if a traveller is a confirmed case is not feasible during exit screening. II. Planning for Exit Screening Prior to the implementation of exit screening, a SOP should be developed in consultation with stakeholders and responsible parties. Suggested parties include, but are not limited to: government entities with jurisdiction such as customs and immigration, public health authorities, civil aviation and maritime authorities, airport or port authorities and managers, conveyance operators, and security personnel. These entities will lead the implementation of the exit screening process and manage available resources. Separate SOPs may be required for airport and port facilities. Identifying Points of Entry Terminals and Locations for Exit Screening As part of the development of the SOP, an assessment should be conducted to determine which departure terminals (particularly for international departures) at Points of Entry (PoE) warrant exit screening, the best location to conduct primary and secondary screening, staffing and training needs, and necessary supplies including non-contact thermometers, Personal Protective Equipment (PPE), and communication materials. As a general principle, travellers should be subject to exit screening control as early as possible upon arrival at the airport or port facility, in conjunction with existing security procedures. If feasible, airport and port authorities may restrict entry to the facility to travellers only and conduct exit screening close to the entry points, prior to check-in and baggage drop-off. In facilities without security at entry, exit screening should be conducted in front of or near the security systems at departure. The legal mechanisms for exit screening, including the necessary authority to issue travel restrictions, should be considered while developing the SOP. Plans should be developed World Health Organization 5

6 with regard to local, national, and international public health, customs and border protection, and travel entities. This should be done in conjunction with the completion of IHR core capacity assessments at PoE. III. Communication Strategies for Exit Screening The exit screening process should include an extensive public health communications campaign to educate travellers and the travel industry. These messages should provide important health information about the outbreak, as well as the intent to screen travellers for signs of disease and risk of exposure to EVD. Messages should include the following: Travellers who are sick should consider postponing travel. Any person with an illness consistent with EVD will not be allowed to travel unless the travel is part of an appropriate medical evacuation; Travellers should plan to arrive early at the travel facility and expect delays related to public health screening; Travellers will be required to complete a Traveller Public Health Declaration, and these questionnaires will be reviewed prior to clearance to board; Temperature measurement will be required, in addition to normal security provisions; Boarding may be denied based on public health criteria. WHO has published the following template for communication to travellers: 1 Infection occurs through contact with blood, body fluids or tissues of an infected symptomatic person, or the body of a person who has died from Ebola, or by contact with contaminated objects. Persons who come into direct contact with an infected symptomatic person or infected animal or with the body of a person who has died from Ebola are at risk. Avoid all contact with blood, body fluids, and tissues of sick people, even after their death. Do not handle items that may have been in contact with an infected person. Symptoms include fever, weakness, muscle pain, headache and sore throat. This is followed by vomiting, diarrhoea, rash, and, in some cases, bleeding. Simply being in proximity to a healthy-looking person (for example, in a public transport conveyance) does not constitute a risk. There is no approved vaccine. Practise careful hygiene, especially hand hygiene with an alcohol-based hand rub solution (hand sanitizer), if available, and with soap and water when hands are visibly soiled. Practise hand hygiene especially before touching eyes, nose or mouth, and after using the toilet or touching objects at high risk of being contaminated. 1 WHO Ebola Travel and Transport Risk Assessment World Health Organization 6

7 If you stayed in the areas where Ebola cases have been recently reported seek immediate medical attention if you feel ill (fever, headache, achiness, sore throat, diarrhoea, vomiting, stomach pain, rash, or red eyes). Early treatment improves the chance of recovery. IV. Primary Screening Traveller completes public health ques onnaire, has temperature measured. Primary screening personnel assess visually for illness and review traveller public health ques onnaire. Is traveller exhibi ng signs or symptoms of EVD? Has Traveller answered yes on traveller public health ques onnaire? Does traveller have temperature above 38 C.? If yes to at least one ques on, refer for secondary screening. Boarding is refused un l evalua on is completed Traveller may con nue to check- in if: all answers to ques ons on the traveller public health ques onnaire are no they do not appear to exhibit any of the signs and or report any symptoms of disease AND they do not have a fever of 38 degrees Celsius or degrees Fahrenheit or higher PRIMARY SCREENING Figure 1. Primary Screening Algorithm Primary screening is a process that identifies travellers who may be symptomatic with, or were possibly exposed to, EVD. Personnel without public health or medical training can conduct this initial screening. Activities (Figure 1) include observing travellers for signs of the disease, temperature measurement, and the distribution 2, collection, and review of a public health questionnaire to determine risk. The following travellers should be referred to secondary screening for further evaluation. Boarding should be refused until further assessment and recommendations are made during the secondary screening process. 2 Travellers may be directed to pick up and complete the public health questionnaire at entry to the point of departure to facilitate screening. World Health Organization 7

8 A. Travellers who exhibit at least one of the signs or symptoms of illness consistent with EVD: fever greater than 38 C 3 or F, or feeling feverish severe headache muscle pain vomiting diarrhoea stomach or abdominal pain unexplained bleeding or bruising B. Travellers who have been identified through primary screening to be at risk of EVD exposure: Activities that put travellers at risk of EVD exposure include: Direct physical contact or caring for an individual with Ebola in the household or in a health-care setting without the appropriate use of PPE, or accidental exposure to body fluids of an Ebola patient despite the use of PPE (e.g. needle stick injuries); Engaging in the preparation of bodies or burial rites for those who have died from EVD, without the appropriate use of PPE; Working in a laboratory where EVD samples are processed without using appropriate PPE or following biosafety precautions. Information on the potential risk of EVD exposure will be captured on the Traveller Public Health Declaration Form and will be reviewed by primary screening personnel. These travellers should also be refused boarding until a further assessment of risk is conducted during secondary screening, even if they are not exhibiting any symptoms or signs of disease. A sample template of a Traveller Public Health Declaration Form is provided in Appendix 2. Implementation of Primary Screening All travellers will be required to complete a Traveller Public Health Declaration Form for each member of the travel party, at entry to the facility. The Traveller Public Health Declaration Form will be used to assess risk of exposure, and for travellers to self-report any symptoms they have experienced within the past 48 hours, or exposures during the past 21 days. Adults may complete the Traveller Public Health Declaration Form for children or assist adults in their party who are unable to complete the questionnaire for a range of reasons. 3 Temperature inclusion criteria may need to be adjusted based on the temperature device used for screening. Calibration recommended. We suggest for primary screening 38 C or F, which is lower than the temperature used for secondary screening for high fever (38.6 C or F). World Health Organization 8

9 Primary screening personnel should review the answers to this questionnaire, while observing travellers for symptoms and signs consistent with EVD, and conducting a noncontact temperature measurement (see footnote on page 8). Travellers who answer yes to any part of the questionnaire should be referred to secondary screening for further evaluation. Travellers who exhibit signs of disease or report symptoms consistent with EVD should also be referred to secondary screening. Travellers with a fever of 38 C (100.4 F ) or higher, as measured during primary temperature screening, or those who report feeling feverish, should also be referred to secondary screening. Temperature measurement is intended for suspected ill travellers and is only one element of the screening process. The temperature of 38 C has been adopted to provide for the sensitivity of temperature measurement devices. All travellers referred to secondary screening should be refused boarding until further evaluation and assessment of risk exposure can be conducted. Travellers may continue travelling after primary screening if: All answers to questions on the Traveller Public Health Declaration Form are no ; They do not appear to exhibit any of the signs and/or report any symptoms of disease; AND They do not have a fever of 38 C (100.4 F) or higher. Operational Considerations for Primary Screening o Establish a system to provide Traveller Public Health Declaration Forms to all travellers as soon as they arrive at the airport, port or ground crossing point of departure; o Select and train primary screening staff to conduct visual screening of travellers. Primary screening staff do not need medical or public health training; o Use appropriate PPE and other infection prevention and control precautions (e.g. hand hygiene) when assessing ill travellers (see table 1 below). PPE guidance should be provided by a public health agency. Ensure sufficient PPE is available, and that staff are trained to use it correctly; o Choose security personnel to provide crowd control; o Select PoE workers to limit access to primary screening areas; o Ensure that non-contact thermometers are calibrated and tested periodically for accuracy (in accordance with manufacturers instructions). Confirm the allowable range of temperatures as described by manufacturers; o Select escorts for ill travellers or potentially exposed travellers to take them to secondary screening; o Arrange baggage assistance and security for travellers referred to secondary screening; World Health Organization 9

10 o Disinfect temperature screening equipment; o Ensure routine sanitation in all PoE facilities, including use of hand sanitizers for travellers; o Take into consideration the sensitivity of temperature measurement equipment. The temperature cut-off point for further evaluation needs to be lower than 38.6 C to correct sensitivity variations. For instance, 38 C is applied in the Traveller Public Health Declaration Form. Table 1. Infection Prevention and Control (IPC) precautions for primary screening personnel Wear gloves; Keep at least a 1 metre away from travellers to be screened as much as possible; Avoid touching travellers as much as possible; If a traveller is found to have fever or becomes unwell during screening, avoid touching the sick person and immediately call secondary screening personnel for further evaluation and clinical management; Perform hand hygiene with an alcohol-based handrub solution or soap and water after glove removal. World Health Organization 10

11 V. Secondary Screening Traveller referred for further evalua on. Secondary screening includes public health interview, comple on of secondary screening form, addi onal temperature measurement. This may also include focused medical examina on. Public health interview and comple on of secondary screening form by screening personnel + + Temperature measurement Focused Medical examina on Evalua on by secondary screeners with guidance from public health authori es Deny boarding to traveller. Refer to medical facility for treatment or public health observa on or monitoring Travellers may con nue to check- in if: they have no known risks for EVD exposure as determined by the secondary screening public health interview, they do not appear to exhibit any of the signs or report any symptoms consistent with EVD as determined by the secondary screening public health interview, AND they do not have a fever 38.6 degrees Celsius or degrees Fahrenheit or higher, as verified during the secondary screening Secondary Screening Figure 2. Secondary Screening Algorithm Secondary screening concerns those travellers identified by primary screening as needing further evaluation for illness or risk of exposure to EVD. Personnel with public health or medical training should conduct secondary screening. Individuals referred to secondary screening should undergo an in-depth interview conducted by a public health or medical professional. Responses to the Traveller Public Health Declaration Form should be verified, and a focused medical examination and second temperature measurement should be conducted. The completed Traveller Public Health Declaration Form, including remarks from primary screening officers, should be attached to secondary screening interview forms to assist in record-keeping. Final determinations about travel restrictions and public health measures, including referral for medical evaluation and treatment, public health observation or monitoring, and notifying national public health authorities, should be made following secondary screening. World Health Organization 11

12 Travellers who exhibit clinical signs and symptoms consistent with EVD as confirmed by secondary screening should be denied boarding and referred for additional medical evaluation and treatment. Appropriate public health authorities should also be notified. Travellers confirmed by secondary screening to be at risk of exposure to EVD should be denied boarding until the 21-day incubation period ends. These travellers should be given communication materials with messages about the outbreak and where to seek treatment if symptoms develop. The appropriate public health authorities should be notified and arrangements made to provide daily monitoring of these individuals for the incubation period commencing from possible exposure to EVD. Restrictions on national and international travel should be implemented. As recommended by the IHR Emergency Committee, any person with an illness consistent with EVD should not be allowed to travel unless it is part of an appropriate medical evacuation (e.g. air ambulance). Clearance procedures for medical evacuations should be planned in advance. Travellers may continue travelling after secondary screening if: They have no known risk of EVD exposure as determined by the secondary screening interview; They do not appear to exhibit any of the signs or report any symptoms consistent with EVD as determined by the secondary screening interview; AND They do not have a fever of 38.6 C or F or higher, as verified during the secondary screening. Operational Considerations for Secondary Screening o Select and train staff to conduct secondary screening of travellers, as needed. Staff conducting secondary screening should have some medical or public health training. o Identify staff to train primary screening personnel on EVD symptom screening and procedures to report possible EVD cases. o Use appropriate PPE and take other precautions (e.g. hand hygiene) when assessing ill travellers (see IPC precautions for secondary screening below). PPE guidance should be given by the national health agency. Ensure sufficient availability of PPE and that staff are trained to use it correctly. o Provide guidance for staff on how to assess travellers for signs and symptoms consistent with EVD. o Have in place a process to refer exposed travellers without EVD symptoms, including travel companions of symptomatic travellers with suspected EVD, to public health authorities for interventions such as symptom monitoring. o Locate and secure temporary space to isolate ill travellers until further evaluation can be arranged. o Prepare educational information for ill or exposed travellers. World Health Organization 12

13 o Establish data management, including data collection on the numbers of travellers screened, and secure storage of completed secondary screening forms. Templates are included for a secondary screening log (Appendix 7), travel companion log (Appendix 4) and secondary screening summary report (Appendix 8). o Set up a process to inform airline, shipping and ground transportation of boarding denials. IPC precautions for secondary screening personnel Wear the following PPE: disposable gloves, long-sleeved impermeable gown, face mask, eye protection (i.e. face shield or goggles), and close-toed shoes with shoe coverings or gum boots. Face mask, eye protection and the addition of a plastic apron if the gown is not impermeable are important particularly if there is any risk of blood or body fluid splashes (e.g. the patient is vomiting, bleeding or has diarrhoea). Carefully follow instructions to put on and to remove and dispose of PPE, to avoid contamination with blood or body fluids. Use PPE to accompany the sick person to the designated area where interview and further evaluation will be undertaken, and then wear PPE only in this area. Perform hand hygiene with soap and water or an alcohol-based handrub solution: o before donning gloves and wearing PPE; o before any clean/aseptic procedures are performed on a patient; o after any exposure risk or actual exposure to the patient s blood and body fluids; o after touching (even potentially) contaminated surfaces/items/equipment in the patient s surroundings; o and after removal of PPE. Change PPE after taking care of each sick traveller. Avoid touching surfaces, items, and people and moving around while wearing PPE to prevent contamination. Don t touch your face or adjust your PPE with contaminated gloves. When removing PPE, dispose of it in infectious waste leak-proof waste bags and covered bins. Do not recycle any single-use disposable PPE. Place any reusable PPE in separate infectious waste leak-proof waste bags and covered bins to be cleaned and decontaminated appropriately. If you are concerned that you may have been exposed to body fluids or other materials from an Ebola patient, stop working and immediately wash the affected skin surfaces with soap and water. Affected mucus membranes should be irrigated with copious amounts of water or eyewash solution. Contact your supervisor for additional follow-up. World Health Organization 13

14 VI. Medical Referral Travellers who exhibit signs and symptoms consistent with EVD during primary and secondary screening will require further evaluation and medical care at a medical facility. A coordination process with local medical facilities, as well as notification of the appropriate public health authorities, should be developed as part of SOPs prior to implementing exit screening. These travellers should be given communication materials with information describing why and where they are being referred for additional medical evaluation and medical care. If the traveller is suspected of having EVD or another communicable disease of public health concern, isolation during transport to the medical facility may be necessary. Consideration should be given to the transportation needs and safety concerns of those transporting the ill traveller. Security and law enforcement needs should be assessed to prepare for potentially non-compliant travellers. These considerations should be addressed in the development of SOP documents. Legal mechanisms compelling individuals to seek medical care should also be considered. All travellers referred for further medical examination after secondary screening should be denied boarding until they no longer pose a public health risk. Additional public health measures such as isolation may also be considered. VII. Travel Restrictions Travel restrictions aim to reduce the risk posed by travellers who may be symptomatic with, or exposed to, EVD. Preventing travellers identified during primary and secondary screening from boarding commercial airplanes, ships, trains or buses helps to prevent the exportation of EVD to other countries. It also protects other passengers and crew, and complies with public health recommendations for exposed persons in affected countries. Legal mechanisms for restricting travel for symptomatic or exposed persons, and for lifting the restriction when a person is no longer considered at risk of infecting others, should be considered. A list of individuals with travel restrictions could be generated by health surveillance systems in advance of attempted travel, and/or from exit screening. This system should take into account that a suspect symptomatic person may be allowed to travel under special medical evacuation transportation arrangements (e.g. air ambulance) and clearance procedures for these situations should be planned. World Health Organization 14

15 VIII. Data Management Data management refers to the process of storing, recording, and disposing of the records captured during exit screening. This may include paper-based record-keeping and/or electronic database creation and data entry, depending on the resources and infrastructure available. Appropriate management of data as part of an exit screening plan provides valuable insight into the scope and effectiveness of screening programs. This information helps to inform future decision-making and implementation considerations. Key functions of data management may include: 1. Conducting a quality assurance review on completed questionnaires, forms, logs and summary reports to ensure that information is legible and complete. 2. Manually extracting information from hard copy questionnaires, forms, logs and summary reports to calculate basic descriptive statistics (e.g., the number of individuals completing primary screening per day). 3. Developing an electronic database in which to enter data from hard copy questionnaires, forms, logs and summary reports to calculate basic and complex descriptive statistics. 4. Adding individuals prevented from travelling to a list of restricted travellers. 5. Cross-checking a list of restricted travellers with the names of travellers during exit screening. References Centers for Disease Control and Prevention, Ebola Outbreak: Airport, Border, & Port of Entry Resources for Use by International Partners. WHO Ebola Event Management at Points of Entry, Interim Guidance. WHO Travel and Transport Risk Assessment, Interim Guidance for Public Health Authorities and the Transport Sector. WHO Statements on the Meeting of the International Health Regulations Emergency Committee Regarding the 2014 Ebola Outbreak in West Africa, 8 August 2014, 22 September 2014, 23 October World Health Organization 15

16 APPENDICES APPENDIX 1: Summary Checklist: Exit Screening at Points of Entry Exit screening is a public health intervention used to identify persons with possible symptoms of, or risk of exposure to, Ebola virus disease (EVD), to prevent them from further travel. Screening measures are based upon risk and can be adapted for airports, land border crossings and sea points of departure. Primary Screening: Identifies travellers with signs, symptoms, or risk of exposure to Ebola. Prior to Implementation: Develop Standard Operating Procedure (SOP) for primary screening Identify: points of departure (international airports, ports and major ground crossings) where primary exit screening will be implemented appropriate location where primary screening will take place within each point of departure Identify staffing needs for: screening personnel security others, e.g., data management, interpreters for specific languages Identify supply needs for temperature screening (e.g., non-contact thermometers, personal protective equipment [PPE]) Purchase supplies needed for temperature screening (including batteries) Train personnel on: primary screening procedures use of non-contact thermometers appropriate use of PPE Develop Traveller Public Health Declaration Form for potential Ebola symptoms or exposure (Appendix 2) Translate Traveller Public Health Declaration Form into relevant languages Develop communication campaign to educate community leaders, travellers and travel industry about the outbreak and the exit screening process (e.g. posters, signs, or other educational media, such as the poster in Appendix 9) Identify data management needs and protocols (e.g. primary screening logs Appendices 5, 6) Implementation: Implement SOP for primary screening Follow PPE guidance for screening personnel Observe travellers for signs and symptoms of disease Distribute, collect, and review public health questionnaire Conduct temperature screening Execute data management strategy Post and distribute communication messages tools If traveller is positive for symptoms/signs or exposure, refer to secondary screening Travellers may continue travelling if: World Health Organization 16

17 all answers to questions on the public health questionnaire are no they do not appear to exhibit any of the signs and symptoms of disease AND they do not have a fever of greater than 38 C or F Secondary Screening: Further assessment of identified travellers to determine if travel restriction or referral for medical evaluation is needed. Prior to Implementation: Identify: ports, airports and ground transport stations where secondary exit screening will be implemented appropriate location where secondary screening will take place within the airport, port or ground crossing health-care facilities to which ill travellers identified by screening will be referred Identify staffing needs for: medical and public health personnel transportation (for possible referrals for further medical evaluation) security others, e.g., data management, interpreters for specific languages Train personnel on: secondary screening procedures use of infrared non-contact thermometers appropriate use of PPE Identify supply needs for temperature screening (e.g., non-contact thermometers, personal protective equipment [PPE]) Purchase supplies needed for temperature screening (including batteries) Develop public health interview for secondary screening assessment (Appendix 3) Translate public health interview questions into relevant languages Develop/distribute communication messages (Appendix 10) Identify data management needs and protocols (e.g. secondary screening logs Appendices 7,8) Implementation: Follow PPE guidance for screeners Conduct a public health interview (Appendix 3) Evaluate passenger for signs and symptoms of disease Repeat temperature screening Travellers should be denied boarding if secondary screening reveals they: Are exhibiting signs and symptoms consistent with Ebola infection Have a fever of greater than 38.6 C or F Are at risk of Ebola exposure within the previous 21 days Referral for additional medical evaluation may be recommended based on secondary screening Travel restrictions and other public health interventions may be implemented Travellers may continue travelling if: all answers to questions on the public health interview are no World Health Organization 17

18 they do not appear to exhibit any of the signs and symptoms of disease AND they do not have a fever of greater than 38.6 C or F Referral for Medical Evaluation/Public Health Notification: Prior to Implementation: Develop SOP for referral to public health or medical authorities (May be included in secondary screening SOP) Identify how travellers will be transported to a medical facility Identify notification procedures for: medical authorities for all referrals appropriate public health authorities Identify security personnel to assist with non-compliant travellers Implementation: Notify appropriate public health authority Notify appropriate medical facility Transport traveller to medical facility Place any traveller referred for further assessment on travel restriction list World Health Organization 18

19 APPENDIX 2: Template: Traveller Public Health Declaration Form If screening is implemented at the Points of Entry in your country, it is highly recommended that public health authorities use the template below. The application of a unified form will facilitate harmonization of international practices and procedures for primary traveller health screening at Points of Entry, during the Ebola outbreak. TRAVELLER PUBLIC HEALTH DECLARATION Please complete this form. The information is being collected as part of the public health response to the outbreaks of Ebola in West Africa. The information will be used by public health authorities in accordance with applicable national laws. TRAVELLER INFORMATION: Flight/ship/train/ground vehicle number/name: Seat/cabin/coach number/name: Last (family) name: First (given) name: Passport country: Passport number: Arrival date: Day. Month.. Year. Birth date: Day. Month... Year. Sex: Male Female address: Telephone number (include country code or country name): Home address: Addresses for next 21 days: World Health Organization 19

20 PUBLIC HEALTH INFORMATION: Today or in the past 48 hours, have you had any of the following symptoms? Yes No a. Fever (38 C / 100 F or higher), feeling feverish, or having chills? b. Vomiting or diarrhoea? c. Severe headaches or body aches? d. Unexplained bruising or bleeding? In the past 21 days, have you done any of the following? Yes No e. Lived in the same household or had other contact (e.g. friends, relatives) with a person sick with Ebola? f. Worked in a health-care facility treating Ebola patients or a laboratory analysing Ebola specimens, or touched a dead body in a country with an Ebola outbreak without using personal protective equipment? Countries Visited: List all countries where you have been in the past 21 days (including airport and port transits and where you live). List the most recent country first (where you boarded). If you need more space, please use the back of the page World Health Organization 20

21 APPENDIX 3: Secondary Screening Form Point of Date of Interview *PLEASE ATTACH TRAVELLER PUBLIC HEALTH DECLARATION FORM USED DURING PRIMARY SCREENING TO THIS DOCUMENT Reason Individual Referred for Secondary Screening (Check All that Apply)*: SECTION 1: TRAVELLER INFORMATION Fever Exposure(s) Other symptom(s) Family name: First name: Other name(s): Age: Date of Birth: / / (DD/MM/YYYY) Gender: Male Female Passport #: Passport Country: Head of Household: Village/Town: Parish: Country of Residence: District: Sub-County: Location Where Traveller Either Became Ill or Had Exposure: Form Village/Town: District: Sub-County: If different from permanent residence, dates residing at this location: / / to / / (DD/MM/YYYY) Date of Exposure (If Applicable): / / (DD/MM/YYYY) SECTION 2: CLINICAL SIGNS AND SYMPTOMS Temperature Has the traveller experienced any of the following symptoms today OR within the past 48 hours? Date of First Symptom Onset: / / (DD/MM/YYYY) Fever ( 38.6 C or F) Yes No Unk If yes, Onset date / / (DD/MM/YYYY) Temp: C Vomiting/nausea Yes No Unk Diarrhoea Yes No Unk Intense fatigue/general weakness Yes No Unk Anorexia/loss of appetite Yes No Unk Abdominal pain Yes No Unk Chest pain Yes No Unk Muscle pain Yes No Unk Joint pain Yes No Unk Headache Yes No Unk Cough Yes No Unk Difficulty breathing Yes No Unk Difficulty swallowing Yes No Unk Sore throat Yes No Unk Jaundice (yellow eyes/gums/skin) Yes No Unk Conjunctivitis (red eyes) Yes No Unk Skin rash Yes No Unk Pain behind eyes/sensitive to light Yes No Unk Confused or disoriented Yes No Unk Unexplained bleeding from any site Yes No Unk If yes: Bleeding of the gums Yes No Unk Bleeding from injection site Yes No Unk Nosebleed (epistaxis) Yes No Unk Blood or black stools (melena) Yes No Unk Fresh/red blood in vomit Yes No Unk (haematemesis) Coughing up blood (haemoptysis) Yes No Unk Bleeding from vagina, other than Yes No Unk menstruation Bruising of the skin Yes No Unk (petechiae/ecchymosis) Other haemorrhagic symptoms Yes No Unk If yes, please specify: Other non-haemorrhagic clinical symptoms Yes No Unk If yes, please specify: UNK = unknown World Health Organization 21

22 SECTION 3: EXPOSURES AND RISK FACTORS In the past three weeks, have you been in any of the following situations? Were you exposed to the blood or other body fluids of a person with Ebola? If yes, did you ever NOT wear waterproof gloves, gown, facemask, and/or goggles? Yes No Unk Did you get pricked by a needle or other sharp object, or get splashed in the eye, nose, or mouth? Did you provide direct care to any person with Ebola while the person was sick? If yes, did you ever NOT wear waterproof gloves, gown, facemask, and/or goggles? Did you work in a laboratory where body fluids of Ebola patients were processed? If yes, did you ever NOT wear waterproof gloves, gown, facemask, and/or goggles? Did you directly handle dead bodies while participating in a funeral or burial rites, or other activities that involve handling dead bodies? If yes, did you ever NOT wear waterproof gloves, gown, facemask, and/or goggles? Have you spent time in the same room as any person with Ebola? If yes, did you ever NOT wear waterproof gloves, gown, facemask, and/or goggles? If yes, were you always at least 1 metre away from the person with Ebola? If yes, did you spend a long period of time in the room (i.e. more than walking past the area)? If yes, did you have any physical contact with the person with Ebola, such as shaking hands or touching any body part? Have you been interviewed as part of a contact tracing investigation after an individual has been confirmed to have Ebola? Yes No Unk Yes No Unk Yes No Unk Yes No Unk Yes No Unk Yes No Unk Yes No Unk Yes No Unk Yes No Unk Yes No Unk Yes No Unk Yes No Unk Yes No Unk Unk = unknown SECTION 4: TRIAGE AND RESPONSE Travel Intervention (check one): Allowed to board flight Not allowed to board flight Medical Assessment and Intervention (check all that apply): Contact Public Health Authority for all transported and referred travellers Transported to hospital/health-care facility Referred home for symptom watch Other, specify: World Health Organization 22

23 APPENDIX 4: Travel Companion List Form Suspect Case Information Surname Other name(s) Phone number Village/Town* Subcounty* District* Date of Onset of Symptoms Dates of Travel* *Please provide information on where the contact will be residing for the next month. Companion Information Surname Other name(s) Phone number Village/Town Subcounty District Sex (M/F) Age (yrs) Relation to suspect case Type of contact (1,2,3,4,5) ** with suspect case; list all **Types of contact with suspect case 1 = Contact with the body fluids of the suspect case (blood, vomit, saliva, urine, faeces) 2 = Direct physical contact with the suspect case 3 = Touched or shared the linens, clothes, and/or dishes/eating utensils of the suspect case 4 = Slept, ate, or spent time in the same household as the case 5 = Travel companion TO BE COMPLETED BY PERSONNEL UNDERTAKING THE SCREENING: Name: Position: Phone: World Health Organization 23

24 APPENDIX 5: Primary Screening Log World Health Organization 24

25 APPENDIX 6: Referred to Secondary Screening Log World Health Organization 25

26 APPENDIX 7: Secondary Screening Log World Health Organization 26

27 APPENDIX 8: Screening Log Summary Reports World Health Organization 27

28 APPENDIX 9: WHO communication poster World Health Organization 28

29 APPENDIX 10: Sample Ill Traveller Card Information for Ill Travelers: Ebola What you need to do You have been given this card because you might have been exposed to patients with Ebola, and because you are sick with symptoms consistent with Ebola infection. This does not mean that you have Ebola, but further evaluation is needed. Ebola is a severe, often fatal disease that spreads through direct contact with an infected person s blood or body fluids (such as saliva or urine). Symptoms appear within 21 days of exposure. People exposed to Ebola are not contagious unless they have a fever and other symptoms of Ebola: severe headache, muscle pain, vomiting, diarrhea, stomach pain, or unexplained bleeding or bruising. Because of your exposure and symptoms, public health officials require that you be medically evaluated. You will be taken to a hospital emergency department. At the hospital, a doctor will examine you. Based on the results of the examination, you might be tested for Ebola, if recommended by public health officials. Follow all instructions by public health and medical personnel to prevent exposing others. If your medical evaluation does not indicate Ebola infection: You will be allowed to leave the hospital. However, continue to take steps to protect yourself and others until 21 days after leaving the Ebolaaffected country: o Take your temperature every morning and evening, and watch for symptoms consistent with Ebola: fever, severe headache, muscle pain, vomiting, diarrhea, stomach pain, or unexplained bleeding or bruising. o Check in regularly with public health officials according to their instructions. o Tell public health officials if you plan to travel more than 50 miles or to another country. o Do not travel on commercial planes, ships, or trains. o Call public health officials immediately if you get a fever* or other symptoms. *Fever: temperature of degrees F / 38 degrees C or higher or feeling like you have a fever. If you can t reach a public health official, call a doctor; tell the doctor where you traveled and that you might have been exposed to Ebola. Do not use public transport to get to the medical facility. Only travel by private car or ambulance. o Bring this notice and give it to health care staff when you arrive. (Sample text for travellers based on CDC recommendations. Adapt as necessary for protocol in country of use.) WHO Ebola website : World Health Organization 29